mangos and urinary retention

Her face was so swollen it was all but unrecognizable. Her right eye was completely shut. Blood caked in streaks and dotted lines ran from her lower lip, down her chin around a large gash under her chin across her neck and spattered her shirt with dark maroon patches like a painted mustang. Out of her left ear and nose dribbled an oily, blood tinged liquid. Patches of bloody cotton stuffed haphazardly into her left ear attempted to control to flow.

She was awake, alert and not afraid despite her small size for her 8 years.

Her father had brought her all the way from Kelo on a motorcycle after she fell from a mango tree that afternoon.

It was Sunday night after a long, busy day at the hospital.

She opened her mouth to reveal a cut inside along the gums leading to a visible mandible fracture. Most of the teeth on the right had been knocked out except one molar on the top, a split molar on the bottom and 4 of her front teeth.

All caused by an addiction to mangos...what can I say, I'm guilty myself.

As I have them prepare for immediate surgery, Lona and Rahama, the nurses on duty, ask me to see an old man who can't pee. Lona tried to pass a foley catheter but was unable to get it into the bladder.

I walk into labor & delivery where they've placed him and see a sobering sight.

A wizened, almost blind man in his 70's is squatting on one of the delivery beds with a wrap half covering his manhood. His chest is bare, sunken and twisted. His scrawny arms still reveal what was once a wiry, tough man.

Blood is smeared all over the table, the wrap, and the man's groin, several clots drip blood from his urethra.

His bladder is swollen halfway to his belly button. I stick a gloved finger up his rectum and confirm a grossly enlarged prostate. He begs to be taken home so he can die. I explain that we will operate on him first thing in the morning, that he won't die. He refuses. We leave the sons to reason with him while Israel, Paul, Sarah and I take the small girl to the OR.

Sarah gives her general anesthesia and I first attempt to wire her jaw. I take a steel suture pass it around the base of her only two molars on the right (the side of the fractures). I twist them together leaving a tail that I then twist together with the molar's twin to bring the jaw together in a functional position. I repeat the process with the front teeth. It's sketchy but is sort of working.

I then open up our internal, maxillo-facial fixation tray and enlarge the wound between her lower lip and chin to expose the fracture. I drill four small holes through a small compression plate, measure the depth of the holes, select the appropriate sized screws and carefully screw them in with a hand screwdriver. Just like I learned in carpentry class (and in the Ventura County Medical Center OR)!

We wash out the wounds well and then I close a couple and Israel closes the rest. She also has a probable basilar skull fracture causing the cerebrospinal fluid to come out her nose and ears. I put her on a strong antibiotic for a week. A few days later the swelling is almost gone and her pain is controlled with ibuprofen and tylenol. After a week of IV antibiotics the leaking has stopped and she goes home.

Meanwhile, I come out of the OR to find that the man with the enlarged prostate is at the gate and would've been home already if the night watchman hadn't blocked his leaving.

As I walk up under the starry Chadian sky a huge part of me wants to just yell at him for being so stupid and let him go home to die. He refuses to wait for the morning saying he'll die before then.

The air is cool and I am tired. It's 11pm already. But, an unfortunately rare thought enters my
head...what if it was my dad? My grandpa? Me? What would I want done?

I offer to operate right now. After much discussion and suspicious glances thrown my way by the old man, his sons convince him.

We carry him to the OR, prep him and give him a spinal anesthetic. I scrub my already well scrubbed hands. I'm almost in a dream, a moment frozen in time as my hands go through the automatic ritual of nails, fingers, hands, wrists to the elbows that has been drilled in me. It's a comforting and important ritual.

I open the OR door with my back, dripping elbows out and hands up. I grab a towel, dry my hands slowly and methodically and drop the towel on the floor. I grab the gown, shake it out and slide my hands through. I'm in another world. I put on my sterile gloves and then Israel and I place the sterile towels around the lower abdomen of the man and then lay on the drape.

After prayer, I take the scalpel and slice horizontally through the skin right above the syphysis pubis...the same as for a c-section. I cut down to the fascia and just through to the muscle on either side of the mid-line. I take the scissors, spread them under the fascia to detach the muscles and cut to the edges of the skin incision both ways. I grab the fascia with clamps, lift up and with my fingers and scissors take the muscles off first superiorly and then inferiorly. I split the muscles with a clamp, insert my fingers and pull the muscles apart. Israel inserts retractors and I open the bladder with the scalpel in a vertical incision. Israel uses the suction tubing to sop up the fountain of urine that pours out. I extend the incision with the scissors.

Israel sucks out all the urine and then pulls the wound open with the retractors. I find the posterior part of the prostate and make a nick with the scalpel. Then we pull out all clamps and retractors and I stick my finger into the bladder, find the small incision and push into the mucosa around the prostate and then sweep around the prostate, shelling it out. Blood pours into the bladder as I lift out the trophy.

Paul inserts a small urethral dilater from below, I attach a heavy suture to the dilator, and Paul pulls it out the urethra. He then ties the suture to a large foley catheter which is then guided into the bladder around the false track. Paul inserts 30ml of water and yanks the foley down into the hole that used to have the prostate.

Israel and I close the bladder, fascia and skin while Paul attaches the irrigation tubing to the three way foley catheter as bloody fluids start coming out into the urine bag.

The next day, our man, who I find out lives in our same neighborhood, is pleasantly surprised to find himself still alive. He's even more surprised to find out a week later that he is going home in very good condition with normal urine function...the only draw back is that he has to suffer through a large indwelling catheter for another week. He smiles, grabs my hand with both his and repeats over and over "Lapia, merci beja, lapia, lapia, lapia..."

( P.S. for other similar email stories look to bereadventisthospital.blogspot.com )

James